Foreword

With the publication of the third volume of To Improve Health and Health Care: The Robert Wood Johnson Foundation Anthology, it is timely to consider how the series is doing and whether it is meeting our expectations. A formal evaluation will be conducted in two or three years. Even in the absence of an evaluation, however, we can make preliminary assessments based on book reviews, reader comments to the Foundation staff and board, and an examination of the three volumes that have appeared to date.

Our original idea was to produce a readable book that would provide an in-depth, unbiased look at a wide range of the Foundation's activities. We hoped it would interest our traditional audience of health policy and research professionals, academics, government officials, foundation executives, service providers and journalists—and go beyond it by attracting members of the public interested in, but not necessarily knowledgeable about, health or philanthropy.

More concretely, the book has three fundamental objectives: first, to demystify the world of philanthropy, at least as practiced by the Robert Wood Johnson Foundation; second, to furnish a public accounting of the Foundation's program investments; and third, to offer lessons gained from more than a quarter century of grantmaking. My impression is that we are doing pretty well in reaching the first two objectives but less well in reaching the third. Let me elaborate.

Foundations can seem daunting from the outside—mysterious places with arbitrary priorities where, through a kind of alchemy, some proposals receive funding while others are turned down. For the Anthology series, we have commissioned a number of chapters—largely written by insiders—that attempt to explain how the Foundation works. Robert Hughes's chapter (1998–1999 Anthology) described in some detail how the Foundation entered the substance abuse field. Jim Knickman's chapter in this volume examines the Foundation's research strategy. Victoria Weisfeld's chapter (1998–1999 Anthology) provided the rationale behind the Foundation's radio and television grants. In my own Foreword for the 1998–1999 Anthology, I articulated the core values that frame our priorities and grantmaking strategies. Taken together, these chapters provide keys that allow interested readers to begin unlocking the mysteries of this large national philanthropy and possibly others as well.

In the Foreword to the first Anthology, I noted that a single volume can offer only a glimpse of the Foundation's interests but that "a more complete picture will emerge with the publication of future volumes." With three volumes now under our belt, I believe that picture is emerging. The tables of contents from this year's Anthology and the previous two volumes show the rich panoply of programs that the Foundation supports in order to improve the health and health care of Americans. If I have any qualms, it is that some authors—despite our admonitions to be tough-minded—have not been sufficiently critical. Still, I believe that the Anthology series offers the public an in-depth, fair and accurate portrayal of the Foundation's philosophy and programs.

Although the Anthology series reveals a great deal about the Robert Wood Johnson Foundation, it is not, as one review pointed out, the best way to learn about a given subject. Even though, for example, the Foundation funded much important research in medical malpractice and health care for the homeless, the Anthology chapters on these topics offer a limited perspective. The same could be said for most topics.

The most problematic aspect of the Anthology series is, in my judgment, drawing lessons from Foundation-supported programs. A number of obstacles help to explain this. First, programs often focus on limited goals, such as developing immunization registries or increasing the number of minority medical faculty members, the lessons from which may be idiosyncratic and not easily generalizable to other initiatives. Second, when broader lessons are drawn, they are often too general to be useful to those charged with developing and implementing programs. Third, the background of the writer influences the lessons drawn: evaluators may be objective outside sources, but sometimes they become partisans for programs; journalists, who often are keen observers and clear writers, rely largely on interviews that may not provide a complete picture; national program officers, although very knowledgeable, may lack the distance to be objective about their own programs.

Despite these limitations, many chapters have succeeded in providing useful lessons. Beth Stevens's and Larry Brown's chapter on state health reform (1997 Anthology), Joanne Lynn's chapter on end-of-life measures (1997 Anthology ), and Rona Henry and her colleagues' chapter on adult day centers in this volume come to mind, but there are others, too. In this issue's Introduction, Stephen Isaacs and Jim Knickman offer lessons that they have culled after reviewing each of the Anthology's chapters.

At a time when the public is demanding that foundations be more accountable, the Anthology series is a tangible demonstration of our commitment to letting the public know, in as objective a manner as possible, what we do and why we do it. We have not wholly achieved our goals, but, in conjunction with the Foundation's Annual Report, our newsletter Advances, a Web site, and online Grant Reports and National Program Reports, I believe that we have taken great strides toward opening our Foundation's philosophical and programmatic books to public scrutiny.

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